Ligature and/or Suicide Risk Reduction - Environmental Risk Assessment Expectations in Non-psychiatric Units/Areas in General Hospitals
What are The Joint Commission's expectations for an environmental risk assessment in non-psychiatric units/areas in general hospitals where patients at risk for suicide are housed (for example, non-designated patient rooms within medical/surgical units, emergency departments)?
Any examples are for illustrative purposes only.
The Joint Commission requires:
Additional Resources
Suicide Prevention Portal
The Joint Commission requires:
- Thoughtful evaluation of the environment,
- A plan, and
- Available resources to guide staff when housing patients at risk for suicide in a patient room in a non-designated space.
The evaluation is meant to be a proactive process to, at a minimum, identify self-harm issues prior to the patient being placed in the room. The plan needs to address who is responsible to remove any objects identified to be of a self-harm nature and resources to guide staff, which may include but are not limited to:
- Checklists identifying the self-harm objects to be removed
- Electronic flags (e.g. the patient you are placing in a medical/surgical room is high risk and you should sweep the room for items not essential for patient care which may pose a self-harm risk)
- Competency/training for all sitters who will be with high risk patients to do the environmental assessments
- Visual reminders (e.g., posters) of the most common items that are significant risks on the unit
- On-site psychiatric professional who is available to complete an environmental risk assessment in areas where staff do not have the training to do this independently
Suicide Prevention Portal
Manual:
Critical Access Hospital
Chapter:
National Patient Safety Goals NPSG
Last reviewed by Standards Interpretation: February 01, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: February 24, 2020
This Standards FAQ was first published on this date.
This page was last updated on February 01, 2022
with update notes of: Review only, FAQ is current
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
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